Washington POLST FormWashington POLST Form
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HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY

Physician Orders for Life-Sustaining Treatment
First follow these orders, then contact physician, nurse practitioner
or PA-C. The POLST is a set of medical orders intended to guide
emergency medical treatment for persons with advanced life limiting
illness based on their current medical condition and goals. Any section
not completed implies full treatment for that section. Everyone shall
be treated with dignity and respect.

Last Name - First Name - Middle Initial
Last 4 #SSN

Date of Birth

Gender

M

F

Agency Info/Sticker

Medical Conditions/Patient Goals:

A
Check
One

B
Check
One

Cardiopulmonary Resuscitation (CPR): Person has no pulse and is not breathing.
DNAR/Do Not Attempt Resuscitation (Allow Natural Death)
CPR/Attempt Resuscitation
Choosing DNAR will include appropriate comfort measures and may still include the range of
treatments below. When not in cardiopulmonary arrest, go to part B.

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